Provider Demographics
NPI:1609374750
Name:ROTH, JILLIAN LEIGH (LCSW)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEIGH
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 DUNELLEN AVE
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-2227
Mailing Address - Country:US
Mailing Address - Phone:908-616-4273
Mailing Address - Fax:
Practice Address - Street 1:20 NASSAU ST STE 412&413
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08542-4509
Practice Address - Country:US
Practice Address - Phone:908-616-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL060715001041C0700X
NJ44SC057728001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical